Comparing potentially avoidable hospitalization rates related to ambulatory care sensitive conditions in Switzerland: the need to refine the definition of health conditions and to adjust for population health status

Primary Health Care Interventions for Potentially Preventable Ear, Nose, and Throat Conditions in Rural and Remote Areas: A Systematic Review

Background:Primary and secondary level preventive primary health care programs providing early detection and timely management of ear, nose, and throat (ENT) conditions in rural and remote regions are fundamental to preventing downstream impacts on health, social, and educational outcomes. However, the range and quality of evidence is yet to be reviewed. Objectives: The study objectives were to identify and synthesize the evidence of primary health care interventions for detection and management of ENT conditions in rural and remote areas, and evaluate the quality of the research and effectiveness of interventions. Methods: A systematic literature search of 6 databases (February 2023). The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, and the quality appraisal of studies was evaluated using the Mixed Methods Appraisal Tool (initial screening questions: Are there clear research questions? Do the collected data allow to address the research questions?). Results: Ten studies met the inclusion criteria. The results describe interventions for detection and management of respiratory tract infections, otitis media, and ear disease in primary health care settings. No studies met the inclusion criteria for tonsillitis. The role of community-based programs and allied health workers in the detection and management of ENT conditions was found to be effective in rural and remote regions. Only 2 of the studies met the screening criteria for quality appraisal. Conclusions: The study findings may inform future programs and policy development to address detection and management of ENT conditions in rural and remote primary care settings, and supports the need for further research on innovative models of care targeting potentially preventable hospitalizations through primary and secondary level prevention.

Potentially avoidable hospitalizations and socioeconomic status in Switzerland: A small area-level analysis

The Swiss healthcare system is well known for the quality of its healthcare and population health but also for its high cost, particularly regarding out-of-pocket expenses. We conduct the first national study on the association between socioeconomic status and access to community-based ambulatory care (CBAC). We analyze administrative and hospital discharge data at the small area level over a four-year time period (2014 - 2017). We develop a socioeconomic deprivation indicator and rely on a well-accepted indicator of potentially avoidable hospitalizations as a measure of access to CBAC. We estimate socioeconomic gradients at the national and cantonal levels with mixed effects models pooled over four years. We compare gradient estimates among specifications without control variables and those that include control variables for area geography and physician availability. We find that the most deprived area is associated with an excess of 2.80 potentially avoidable hospitalizations per 1,000 population (3.01 with control variables) compared to the least deprived area. We also find significant gradient variation across cantons with a difference of 5.40 (5.54 with control variables) between the smallest and largest canton gradients. Addressing broader social determinants of health, financial barriers to access, and strengthening CBAC services in targeted areas would likely reduce the observed gap.

A five year descriptive analysis of potentially preventable hospitalisations for Ear, Nose, and Throat conditions in regional Victoria, Australia, from 2015 to 2020

BACKGROUND

Potentially preventable hospitalisations of ear, nose, and throat conditions in the Murray Primary Health Network region have been found to be higher than the state average of Victoria, Australia. This study aimed to examine the association between selected patient-level characteristics and the likelihood of residing in a Murray PHN postcode with higher than expected numbers of potentially preventable ENT hospitalisations.

METHODS

Unit record hospital separation data were obtained from the Victorian Admitted Episodes Dataset. Postcodes were classified as having higher than expected numbers of potentially preventable hospitalisations across three subgroups of ENT using indirect standardisation techniques. Differences between patients from 'higher than expected' postcodes and 'other' postcodes with respect to the distribution of demographic and other patient characteristics were determined using chi-squared tests for each ENT subgroup. The results were confirmed by logistic regression analyses using resident of a postcode with higher than expected hospitalisations as the outcome variable.

RESULTS

Of the 169 postcodes located in the catchment area, 15 were identified as having higher than expected numbers of upper respiratory tract infection hospitalisations, 14 were identified for acute tonsillitis, and 12 were identified for otitis media. Patients from postcodes with 'higher than expected' hospitalisations for these conditions were more likely than others to be aged between 0 and 9 years, Indigenous, or from a culturally and linguistically diverse background.

CONCLUSION

Further investigation of the identified postcodes is warranted to determine access to and utilisation of primary healthcare services in the management of PPH ENT conditions in the region.

Potentially Avoidable Hospitalizations by Asthma and COPD in Switzerland from 1998 to 2018: A Cross-Sectional Study

Potentially avoidable hospitalizations (PAH) are commonly used as an indicator for healthcare quality and primary care performance. However, data are usually presented in a restricted timeframe and for a specific region, limiting the identification of trends and national patterns. We aimed in this study to calculate rates, identify clinical determinants, and estimate costs of PAH for two frequent lung diseases (asthma and COPD) in Switzerland between 1998 and 2018 using hospital discharge data available for patients aged ≥20 years. PAH were defined according to the Health Care Quality Indicators Project (HCQIP) from the Organisation for Economic Co-operation and Development (OECD). The distribution of PAH in seven administrative regions (Leman, Mittelland, Northwest, Zurich, Eastern, Central, and Ticino) was calculated, along with PAH-associated total hospital days and Diagnosis-Related Group (DRG) estimated costs. Totals of 25,260 PAH for asthma and 135,069 PAH for COPD were identified in the 20-year period. The standardized rates of PAH per 100,000 people for asthma fluctuated from 18.7 in 1998 to 22.5 on 2018. The standardized rates of PAH per 100,000 people from COPD almost doubled from 77.4 in 1998 to 142.7 in 2018. In 2018, the estimated total costs of PAH amounted to 7.7 million CHF for asthma and 91.2 million CHF for COPD. We conclude that PAH for asthma and COPD represent a significant and unnecessary burden and costs of hospitalizations in Switzerland.

Understanding potentially avoidable hospitalisations in a rural Australian setting from the perspectives of patients and health professionals: a qualitative study and logic model

Background

Potentially avoidable hospitalisations (PAHs) are proxy measures of effective primary care at a population level. PAHs are higher in rural and disadvantaged areas. This qualitative study sought a deeper understanding of PAHs for chronic health conditions in a rural context from the perspectives of patients and health professionals, and aimed to develop a logic model for rural health services to identify intervention targets.

Methods

Patients with chronic obstructive pulmonary disease, congestive cardiac failure or type 2 diabetes, admitted to a rural hospital in Australia and local health professionals were invited to participate in interviews in late 2019. Semistructured interviews were recorded, transcribed verbatim and thematically analysed. Themes were mapped against a programme logic model developed in a similar study.

Results

patients and 16 health professionals participated. The logic model encompassed patient level (knowledge, skills, health status), provider level (workforce availability, attributes) and system level (clinical pathways) contexts. These contexts influenced key mechanisms of relationships, continuity of care and capacity to offer services. Outcomes included responsive and timely access to care, improved clinical outcomes and resource use. Themes that did not readily map to the logic model included socioeconomic disadvantage and healthcare costs, which influenced affordability and equity of access.

Conclusion

Patients’ complex health and social circumstance, health service access and unclear care pathways were strong themes associated with PAH in this rural context. Patient, provider and system contexts influencing key mechanisms and outcomes need to be understood when designing solutions to address PAHs in rural settings. Ideally, interventions should address the cost of healthcare alongside interventions to enhance relationships, continuity of care and capacity to offer services.

Measuring medically unjustified hospitalizations in Switzerland

Background

Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics.

Methods

The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. “unjustified” and “sometimes justified” stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse).

Results

Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for “unjustified stays” and 17% for “sometimes justified stays”. Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions’ monitoring, pain management, falls prevention, and specialized at-home services that should be offered.

Conclusion

We recommend using “unjustified stays” and “sometimes justified stays” indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07569-3.

Hospitalization for Primary Care-Sensitive Conditions in Adults and Its Impact on Hospital Care in São Paulo City, Brazil

INTRODUCTION

Identifying conditions among all cause hospitalizations that could be prevented at the primary care level would allow the development of strategies to reduce the range of diseases treated in hospital and promote a more efficient utilization of resources.

OBJECTIVE

We sought to evaluate hospitalizations for clinical conditions that are sensitive to primary care in adults.

METHODS

Cross-sectional study with data captured in hospital electronic health records using the diagnosis related groups classification system.

RESULTS

Primary care-sensitive conditions were associated with longer duration of hospitalization, older age, higher prevalence of female patients, higher complexity at admission and during hospitalization, and a higher risk of mortality as compared with other conditions not sensitive to primary care.

CONCLUSION

A significant proportion of hospitalizations are due to causes sensitive to primary care. Hospitalizations due to primary care-sensitive conditions are associated with longer hospital stay, greater complexity and severity, and a higher risk of mortality.

Regional variation of potentially avoidable hospitalisations in Switzerland: an observational study

Background

Primary health care is subject to regional variation, which may be due to unequal and inefficient distribution of services. One key measure of such variation are potentially avoidable hospitalisations, i.e., hospitalisations for conditions that could have been dealt with in situ by sufficient primary health care provision. Particularly, potentially avoidable hospitalisations for ambulatory care-sensitive conditions (ACSCs) are a substantial and growing burden for health care systems that require targeting in health care policy.

Aims

Using data from the Swiss Federal Statistical Office (SFSO) from 2017, we applied small area analysis to visualize regional variation to comprehensively map potentially avoidable hospitalisations for five ACSCs from Swiss nursing homes, home care organisations and the general population.

Methods

This retrospective observational study used data on all Swiss hospitalisations in 2017 to assess regional variations of potentially avoidable hospitalisations for angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, diabetes complications and hypertension. We used small areas, utilisation-based hospital service areas (HSAs), and administrative districts (Cantons) as geographic zones. The outcomes of interest were age and sex standardised rates of potentially avoidable hospitalisations for ACSCs in adults (> 15 years). Our inferential analyses used linear mixed models with Gaussian distribution.

Results

We identified 46,479 hospitalisations for ACSC, or 4.3% of all hospitalisations. Most of these occurred in the elderly population for congestive heart failure and COPD. The median rate of potentially avoidable hospitalisation for ACSC was 527 (IQR 432–620) per 100.000 inhabitants. We found substantial regional variation for HSAs and administrative districts as well as disease-specific regional patterns.

Conclusions

Differences in continuity of care might be key drivers for regional variation of potentially avoidable hospitalisations for ACSCs. These results provide a new perspective on the functioning of primary care structures in Switzerland and call for novel approaches in effective primary care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06876-5.

Individual and Area-level Factors Contributing to the Geographic Variation in Ambulatory Care Sensitive Conditions in Finland: A Register-based Study

BACKGROUND

Measuring primary health care (PHC) performance through hospitalizations for ambulatory care sensitive conditions (ACSCs) remains controversial-recent cross-sectional research claims that its geographic variation associates more with individual socioeconomic position (SEP) and health status than PHC supply.

OBJECTIVES

To clarify the usage of ACSCs as a PHC performance indicator by quantifying how disease burden, both PHC and hospital supply and spatial access contribute over time to geographic variation in Finland when individual SEP and comorbidities were adjusted for.

METHODS

The Finnish Care Register for Health Care provided hospitalizations for ACSCs (divided further into subgroups of acute, chronic, and vaccine-preventable causes) in 2011-2017. With 3-level nested multilevel Poisson models-individuals, PHC authorities, and hospital authorities-we estimated the proportion of the variance in ACSCs explained by selected factors at 3 time periods.

RESULTS

In age-adjusted and sex-adjusted analysis of total ACSCs the variances between hospital authorities was nearly twice that between PHC authorities. Individual SEP and comorbidities explained 19%-30% of the variance between PHC authorities and 25%-36% between hospital authorities; and area-level disease burden and arrangement and usage of hospital care a further 14%-16% and 32%-33%-evening out the unexplained variances between PHC and hospital authorities.

CONCLUSIONS

Alongside individual factors, areas' disease burden and factors related to hospital care explained the excess variances in ACSCs captured by hospital authorities. Our consistent findings over time suggest that the local strain on health care and the regional arrangement of hospital services affect ACSCs-necessitating caution when comparing areas' PHC performance through ACSCs.

Defining ambulatory care sensitive conditions for adults in Portugal

BACKGROUND

Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal.

METHODS

A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions.

RESULTS

After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus.

CONCLUSIONS

New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.

Inefficiencies in a healthcare system with a regulatory split of power: a spatial panel data analysis of avoidable hospitalisations in Austria

Despite generous universal social health insurance with little formal restrictions of outpatient utilisation, Austria exhibits high rates of avoidable hospitalisations, which indicate the inefficient provision of primary healthcare and might be a consequence of the strict regulatory split between the Austrian inpatient and outpatient sector. This paper exploits the considerable regional variations in acute and chronic avoidable hospitalisations in Austria to investigate whether those inefficiencies in primary care are rather related to regional healthcare supply or to population characteristics. To explicitly account for inter-regional dependencies, spatial panel data methods are applied to a comprehensive administrative dataset of all hospitalisations from 2008 to 2013 in the 117 Austrian districts. The initial selection of relevant covariates is based on Bayesian model averaging. The results of the analysis show that supply-side variables, such as the number of general practitioners, are significantly associated with decreased chronic and acute avoidable hospitalisations, whereas characteristics of the regional population, such as the share of population with university education or long-term unemployed, are less relevant. Furthermore, the spatial error term indicates that there are significant spatial dependencies between unobserved characteristics, such as practice style or patients' utilization behaviour. Not accounting for those would result in omitted variable bias.

Hospitalizações infantis por condições sensíveis à atenção primária em cidade brasileira

Objetivo: analisar a evolução temporal das hospitalizações, de crianças menores de cinco anos, por condições sensíveis à atenção primária em Teresina-PI, Brasil, de 2003 a 2012.Métodos: trata-se de estudo retrospectivo, descritivo e quantitativo, realizado a partir de dados secundários extraídos da Rede Interagencial de Informações para a Saúde, disponíveis no sítio eletrônico do Departamento de Informática do Sistema Único de Saúde. As hospitalizações foram analisadas em dois grupos etários: crianças menores de um ano de idade e crianças entre um e quatro anos de idade.Resultados: apesar das flutuações no período analisado, a taxa de hospitalizações teve um decréscimo de 71,88 %. Em crianças menores de um ano, o declínio foi de 71,49 % e, com idade entre um e quatro anos, a redução foi de 72,30 %. A maioria das hospitalizações ocorreu no sexo masculino, e as causas que predominaram foram gastroenterites infecciosas e pneumonias bacterianas.Conclusões: as hospitalizações por condições sensíveis à atenção primária tiveram um declínio ao longo da década analisada, entretanto houve um predomínio de condições sensíveis que poderiam ser evitadas ou até mesmo solucionadas se fossem aplicadas as medidas disponíveis e de baixo custo nos serviços primários de saúde.

Trajectory modelling of ambulatory care sensitive conditions in Finland in 1996-2013: assessing the development of equity in primary health care through clustering of geographic areas - an observational retrospective study

Background

Due to stagnating resources and an increase in staff workload, the quality of Finnish primary health care (PHC) is claimed to have deteriorated slowly. With a decentralised PHC organisation and lack of national stewardship, it is likely that municipalities have adopted different coping strategies, predisposing them to geographic disparities. To assess whether these disparities emerge, we analysed health centre area trajectories in hospitalisations due to ambulatory care sensitive conditions (ACSCs).

Methods

ACSCs, a proxy for PHC quality, comprises conditions in which hospitalisation could be avoided by timely care. We obtained ACSCs of the total Finnish population aged ≥20 for the years 1996–2013 from the Finnish Hospital Discharge Register, and divided them into subgroups of acute, chronic and vaccine-preventable causes, and calculated annual age-standardised ACSC rates by gender in health centre areas. Using these rates, we conducted trajectory analyses for identifying health centre area clusters using group-based trajectory modelling. Further, we applied area-level factors to describe the distribution of health centre areas on these trajectories.

Results

Three trajectories – and thus separate clusters of health centre areas – emerged with different levels and trends of ACSC rates. During the study period, chronic ACSC rates decreased (40–63%) within each of the clusters, acute ACSC rates remained stable and vaccine-preventable ACSC rates increased (1–41%). While disparities in rate differences in chronic ACSC rates between trajectories narrowed, in the two other ACSC subgroups they increased. Disparities in standardised rate ratios increased in vaccine-preventable and acute ACSC rates between northern cluster and the two other clusters. Compared to the south-western cluster, 13–16% of health centre areas, in rural northern cluster, had 47–92% higher ACSC rates – but also the highest level of morbidity, most limitations on activities of daily living and highest PHC inpatient ward usage as well as the lowest education levels and private health and dental care usage.

Conclusions

We identified three differing trajectories of time trends for ACSC rates, suggesting that the quality of care, particularly in northern Finland health centre areas, may have lagged behind the general improvements. This calls for further investments to strengthen rural area PHC.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4449-7) contains supplementary material, which is available to authorized users.

Mental well-being, job satisfaction and self-rated workability in general practitioners and hospitalisations for ambulatory care sensitive conditions among listed patients: a cohort study combining survey data on GPs and register data on patients

BACKGROUND

Physicians' work conditions and mental well-being may affect healthcare quality and efficacy. Yet the effects on objective measures of healthcare performance remain understudied. This study examined mental well-being, job satisfaction and self-rated workability in general practitioners (GPs) in relation to hospitalisations for ambulatory care sensitive conditions (ACSC-Hs), a register-based quality indicator affected by referral threshold and prevention efforts in primary care.

METHODS

This is an observational study combining data from national registers and a nationwide questionnaire survey among Danish GPs. To ensure precise linkage of each patient with a specific GP, partnership practices were not included. Study cases were 461 376 adult patients listed with 392 GPs. Associations between hospitalisations in the 6-month study period and selected well-being indicators were estimated at the individual patient level and adjusted for GP gender and seniority, list size, and patient factors (comorbidity, sociodemographic characteristics).

RESULTS

The median number of ACSC-Hs per 1000 listed patients was 10.2 (interquartile interval: 7.0-13.7). All well-being indicators were inversely associated with ACSC-Hs, except for perceived stress (not associated). The adjusted incidence rate ratio was 1.26 (95% CI 1.13 to 1.42) for patients listed with GPs in the least favourable category of self-rated workability, and 1.19 (95% CI 1.05 to 1.35), 1.15 (95% CI 1.04 to 1.27) and 1.14 (95% CI 1.03 to 1.27) for patients listed with GPs in the least favourable categories of burn-out, job satisfaction and general well-being (the most favourable categories used as reference). Hospitalisations for conditions not classified as ambulatory care sensitive were not equally associated.

CONCLUSIONS

ACSC-H frequency increased with decreasing levels of GP mental well-being, job satisfaction and self-rated workability. These findings imply that GPs' work conditions and mental well-being may have important implications for individual patients and for healthcare expenditures.

Disparities in avoidable hospitalization by income in South Korea: data from the National Health Insurance cohort

BACKGROUND

Avoidable hospitalizations can act as an indicator for primary health care quality, in particular ambulatory care sensitive conditions (ACSCs) as hospitalizations for these conditions are generally considered avoidable through successful management. This study aimed to examine whether differences exist between income levels in rates of avoidable hospitalization.

METHODS

The South Korea National Health Insurance claims data from 2002 to 2013 were used. All hospitalizations were included and categorized into avoidable and non-avoidable cases. The independent variable was income level classified into quartiles and the dependent variable rates of avoidable hospitalization. Analysis was conducted using the generalized estimating equation (GEE) Poisson model. Subgroup analysis was performed based on chronic versus acute disease status and urban versus rural region.

RESULTS

A total of 1 310 492 cases were included, in which the crude rate of avoidable hospitalizations was 1444.5 per 100 000 person years. Compared to the Q4 highest income group set as reference, the Q3 (RR 1.07, 95% CI 1.04-1.09), Q2 (RR 1.16, 95% CI 1.13-1.19) and Q1 (RR 1.20, 95% CI 1.17-1.24) income groups showed higher rates of avoidable hospitalizations.

CONCLUSION

Risks of avoidable hospitalizations for ACSCs was higher in lower than higher income groups, implying that socioeconomic status is related to disparities in avoidable hospitalizations. The findings suggest the importance of monitoring the vulnerable groups identified in managing avoidable hospitalizations.

The closer the better: does better access to outpatient care prevent hospitalization?

In 2010-2012, new outpatient service locations were established in poor Hungarian micro-regions. We exploit this quasi-experiment to estimate the extent of substitution between outpatient and inpatient care. Fixed-effects Poisson models on individual-level panel data for years 2008-2015 show that the number of outpatient visits increased by 19% and the number of inpatient stays decreased by 1.6% as a result, driven by a marked reduction of potentially avoidable hospitalization (PAH) (5%). In our dynamic specification, PAH effects occur in the year after the treatment, whereas non-PAH only decreases with a multi-year lag. The instrumental variable estimates suggest that a one euro increase in outpatient care expenditures produces a 0.6 euro decrease in inpatient care expenditures. Our results (1) strengthen the claim that bringing outpatient care closer to a previously underserved population yields considerable health benefits, and (2) suggest that there is a strong substitution element between outpatient and inpatient care.

[Effect of the Family Health Strategy on hospitalizations for primary care sensitive conditions in infants in Bahia State, Brazil]

This study aimed to assess the effect of the expansion of the Family Health Strategy (FHS) on hospitalizations for primary care sensitive conditions (PCSCs) in children under one year of age. This was a longitudinal ecological study with the use of panel data, for which the analytical units were the 417 municipalities (counties) in Bahia State, Brazil, from 2000 to 2012. Data were obtained from the official health information systems. The hospitalization rate for PCSCs was the outcome and FHS coverage was the principal exposure. The co-variables referred to demographic and socioeconomic characteristics and the local availability of pediatric beds. Bivariate and multivariate panel data analyses were performed, with negative binomial response and fixed effects models, using crude and adjusted relative risk (RR) as the measure of association, with the respective confidence intervals. To control for trend effect, the models were adjusted for time. From 2000 to 2012, 248,944 hospitalizations for PCSCs were recorded in children under one year, and the median municipal rate of hospitalizations for PCSCs decreased by 52.5% during the period, ranging from 96.9 to 46.0 avoidable hospitalizations per 1,000 live births. After adjusting the model, the reduction in avoidable hospitalizations was maintained at the different FHS coverage levels. This study demonstrated the effects of the consolidation of the FHS on hospitalizations for PCSCs in infants, which indicates the importance of strengthening primary care measures in order to offer case-resolving care during the first contact with the health system and avoid unnecessary hospitalizations.

Patient safety issues in office-based surgery and anaesthesia in Switzerland: a qualitative study

OBJECTIVES

To identify the spectrum of patient safety issues in office-based surgery and anaesthesia in Switzerland.

METHODS

Purposive sample of 23 experts in surgery and anaesthesia and quality and regulation in Switzerland. Data were collected via individual qualitative interviews using a researcher-developed semi-structured interview guide between March 2016 and September 2016. Interviews were transcribed and analysed using conventional content analysis. Issues were categorised under the headings "structure", "process", and "outcome".

RESULTS

Experts identified two key overarching patient safety and regulatory issues in relation to office-based surgery and anaesthesia in Switzerland. First, experts repeatedly raised the current lack of data and transparency of the setting. It is unknown how many surgeons are operating in offices, how many and what types of operations are being done, and what the outcomes are. Secondly, experts also noted the limited oversight and regulation of the setting. While some standards exists, most experts felt that more minimal safety standards are needed regarding the requirements that must be met to do office-based surgery and what can and cannot be done in the office-based setting are needed, but they advocated a self-regulatory approach.

CONCLUSION

There is a lack of empirical data regarding the quantity and quality office-based surgery and anaesthesia in Switzerland. Further research is needed to address these research gaps and inform health policy in relation to patient safety in office-based surgery and anaesthesia in Switzerland.

Sequence Analysis of Long-Term Readmissions among High-Impact Users of Cerebrovascular Patients

Objective

Understanding the chronological order of the causes of readmissions may help us assess any repeated chain of events among high-impact users, those with high readmission rate. We aim to perform sequence analysis of administrative data to identify distinct sequences of emergency readmissions among the high-impact users.

Methods

A retrospective cohort of all cerebrovascular patients identified through national administrative data and followed for 4 years.

Results

Common discriminating subsequences in chronic high-impact users (n = 2863) of ischaemic stroke (n = 34208) were “urological conditions-chest infection,” “chest infection-urological conditions,” “injury-urological conditions,” “chest infection-ambulatory condition,” and “ambulatory condition-chest infection” (p < 0.01). Among TIA patients (n = 20549), common discriminating (p < 0.01) subsequences among chronic high-impact users were “injury-urological conditions,” “urological conditions-chest infection,” “urological conditions-injury,” “ambulatory condition-urological conditions,” and “ambulatory condition-chest infection.” Among the chronic high-impact group of intracranial haemorrhage (n = 2605) common discriminating subsequences (p < 0.01) were “dementia-injury,” “chest infection-dementia,” “dementia-dementia-injury,” “dementia-urine infection,” and “injury-urine infection.” Conclusion. Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.

Conclusion

Although common causes of readmission are the same in different subgroups, the high-impact users had a higher proportion of patients with distinct common sequences of multiple readmissions as identified by the sequence analysis. Most of these causes are potentially preventable and can be avoided in the community.

Impact of Disease Prevalence Adjustment on Hospitalization Rates for Chronic Ambulatory Care-Sensitive Conditions in Germany

OBJECTIVES

To explore effects of disease prevalence adjustment on ambulatory care-sensitive hospitalization (ACSH) rates used for quality comparisons.

DATA SOURCES/STUDY SETTING

County-level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used.

STUDY DESIGN

A retrospective cross-sectional study using in- and outpatient secondary data was performed.

DATA COLLECTION

Hospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care.

PRINCIPAL FINDINGS

Crude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28-37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21-28 percent). Prevalence explained 40-50 percent of the observed variation (r = 0.65-0.70) in ACSH rates for all conditions except asthma (r = 0.07). Between 30 percent and 38 percent of areas moved into or outside condition-specific control limits with prevalence adjustment.

CONCLUSIONS

Unadjusted ACSH rates should be used with caution for high-stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH.

Economic Burden of Avoidable Hospitalizations among Patients with Cancer at Namazi Hospital in Shiraz, 2013

Introduction: Hospitalization of patients with cancer has a significant economic impact and avoidance where unnecessary has great potential for significant cost savings for patients, individual hospitals and the health system in general. Methods: Demographic, clinical and economical data were collected from medical records in our hospital retrospectively. Oncology clinicians reviewed medical records to categorize each hospitalization as “potentially avoidable” or “not avoidable.” Patient demographic and clinical data were abstracted and quantitative and qualitative analyses were performed to identify patient characteristics and outcomes associated with potentially avoidable hospitalizations. Finally data on the cost of the latter were estimated. Results: Of 451 hospitalizations, medical oncologists identified 55 (12.2%) as potentially avoidable. Avoiding these and caring for the patients in alternative locations would save some $ US 641,240 yearly. Among patients with avoidable hospitalization, 70.9% were males and the median age and median length of stay was 55 years and 4.7 days. Most of them had general signs (83.6%) and a fever body temperature lower than 38.5’C (96.4%). Lung, kidney and urinary tract cancers were the most common diagnoses (10.9%). The majority of avoidable hospitalized patients had local cancer (85.5%) and poor performance status (43.6%). The most prevalent procedure for patients with avoidable hospitalization was sonography and the least frequent were laboratory tests and MRI. Most cases received no treatment. Conclusion: Avoidable hospitalizations are common in patients with cancer. Age, final results of hospitalization and length of stay were established as significant variables for patients with avoidable hospitalization.

Visualising linked health data to explore health events around preventable hospitalisations in NSW Australia

OBJECTIVE

To explore patterns of health service use in the lead-up to, and following, admission for a 'preventable' hospitalisation.

SETTING

266 950 participants in the 45 and Up Study, New South Wales (NSW) Australia

METHODS

Linked data on hospital admissions, general practitioner (GP) visits and other health events were used to create visual representations of health service use. For each participant, health events were plotted against time, with different events juxtaposed using different markers and panels of data. Various visualisations were explored by patient characteristics, and compared with a cohort of non-admitted participants matched on sociodemographic and health characteristics. Health events were displayed over calendar year and in the 90 days surrounding first preventable hospitalisation.

RESULTS

The visualisations revealed patterns of clustering of GP consultations in the lead-up to, and following, preventable hospitalisation, with 14% of patients having a consultation on the day of admission and 27% in the prior week. There was a clustering of deaths and other hospitalisations following discharge, particularly for patients with a long length of stay, suggesting patients may have been in a state of health deterioration. Specialist consultations were primarily clustered during the period of hospitalisation. Rates of all health events were higher in patients admitted for a preventable hospitalisation than the matched non-admitted cohort.

CONCLUSIONS

We did not find evidence of limited use of primary care services in the lead-up to a preventable hospitalisation, rather people with preventable hospitalisations tended to have high levels of engagement with multiple elements of the healthcare system. As such, preventable hospitalisations might be better used as a tool for identifying sicker patients for managed care programmes. Visualising longitudinal health data was found to be a powerful strategy for uncovering patterns of health service use, and such visualisations have potential to be more widely adopted in health services research.

Rates of admission for ambulatory care sensitive conditions in France in 2009-2010: trends, geographic variation, costs, and an international comparison

BACKGROUND

Admissions for ambulatory care sensitive conditions (ACSCs) are considered preventable and indicators of poor access to primary care. We wondered whether per-capita rates of admission for ACSCs in France demonstrated geographic variation, were changing, were related to other independent variables, or were comparable to those in other countries; further, we wanted to quantify the resources such admissions consume.

METHODS

We calculated per-capita rates of admission for five categories (chronic, acute, vaccination preventable, alcohol-related, and other) of ACSCs in 94 departments in mainland France in 2009 and 2010, examined measures and causes of geographic variation in those rates, computed the costs of those admissions, and compared rates of admission for ACSCs in France to those in several other countries.

RESULTS

The highest ACSC admission rates generally occurred in the young and the old, but rates varied across French regions. Over the 2-year period, rates of most categories of ACSCs increased; higher ACSC admission rates were associated with lower incomes and a higher supply of hospital beds. We found that the local supply of general practitioners was inversely associated with rates of chronic and total ACSC admission rates, but that this relationship disappeared if we accounted for patients' use of general practitioners in neighboring departments. ACSC admissions cost 4.755 billion euros in 2009 and 5.066 billion euros in 2010; they consumed 7.86 and 8.74 million bed days of care, respectively. France had higher rates of ACSC admissions than most other countries examined.

CONCLUSIONS

Because admissions for ACSCs are generally considered a failure of outpatient care, cost French taxpayers substantial monetary and hospital resources, and appear to occur more frequently in France than in other countries, policymakers should prioritize targeted efforts to reduce them.

Association between Potentially Inappropriate Medication (PIM) Use and Risk of Hospitalization in Older Adults: An Observational Study Based on Routine Data Comparing PIM Use with Use of PIM Alternatives

OBJECTIVE

The safety of potentially inappropriate medications (PIMs) in elderly patients is still debated. Using the PRISCUS list, we examined the incident all-cause hospitalization risk associated with PIMs compared to PIM alternatives during the 180 days post individual first pharmacy dispensing (index date).

METHODS

Routine claims data from a German health insurer on 392,337 ambulatory patients aged ≥65 years, were used to estimate adjusted hazard ratios (HRs) for hospitalization associated with incident PIM use. Observation period was January 2009 -December 2010. Users of PIM alternatives, as defined by the PRISCUS list, were the reference group. Patients with PIM dispensing or hospital stay in a six month "washout" period (second half of 2008) were excluded. All potential confounders were determined in the half year before the individual index date.

RESULTS

In the total cohort 60.7% were female. Median age was 73 years. Of 79,041 incident PIM users, 58.4% had PIMs dispensed in one quarter of 2009 or 2010, 19.3% in two quarters, and 22.3% in three or more quarters. There were 126,535 hospitalizations during the observation period, and 47,470 of them occurred within 180 days post first dispensing. Multivariable Cox regression analysis revealed PIM use as a significant risk factor for hospitalization (HR 1.378; 95% CI 1.349-1.407) compared to use of PIM alternatives.

CONCLUSIONS

PIM use compared to use of PIM alternatives is associated with an increased risk of all-cause hospitalization in the 180 days following individual index date. Future analyses comparing a single PIM with its corresponding alternative may help identify those PIMs responsible for this.

Family and community orientation in children's primary healthcare

This article seeks to identify the principle of family and community orientation in Family Health Units, relating to care for the health of children under the age of 10. It is a quantitative, assessment study of 344 family members and/or carers of children under the age of 10, served in the 53 Family Health units of the 3rd ('IIIrd') Health District of the city of João Pessoa, Brazil. The data were collected based on the Family Orientation and Community Orientation variables present in the children's version of the Primary Care Assessment Tool - Brasil. Analysis took the form of simple frequency distribution statistics. Average scores for the components analyzed were between 3.7 and 5.7, lower than the level of 6.6 which is determined for these attributes to be oriented to primary healthcare. There is a weak orientation of the attributes Family Orientation and Community Orientation in the primary care of the services evaluated, and this indicates a need for a full approach to the child, with macro- and micro-political conceptions by those planning and managing healthcare, to ensure that children get full and effective healthcare.

Factors associated with avoidable hospitalisation of children younger than 2 years old: the 2006 Brazilian National Demographic Health Survey

Introduction

Ambulatory Care Sensitive Conditions (ACSC) are conditions for which hospitalisation is thought to be avoidable with the use of effective preventive care and early disease management. The objective of this study was to estimate the rate of avoidable hospitalisations in children younger than 24 months of age participating in a Brazilian national representative survey and to identify the risk factors for such hospitalisations.

Methods

We analysed data from a cross-sectional study of 1901 children from the 2006 Brazilian National Demographic Health Survey of Women and Children (NDHS). The children’s socioeconomic, biological and maternal characteristics, nutritional status, and access to healthcare were tested; variables with p < 0.20 were selected to fit a Poisson regression.

Results

The prevalence of avoidable hospitalisation was 11.8 % (95 % Confidence Interval [CI], 9.0, 15.2); the prevalence was higher in the Southeast (40.1 %) and Northwest (21.7 %) macro-regions. The multivariate model identified five risk factors for avoidable hospitalisation: male gender (Prevalence Ratio [PR] = 1.48, p = 0.004), low socioeconomic level (PR = 1.51, p = 0.005), children from mothers younger than 20 years of age (PR = 1.41, p = 0.031), not breastfed within the first hour of life (PR = 1.29, p = 0.034), and neonatal hospitalisation (PR = 1.66, p = 0.043).

Conclusions

To decrease the costs associated with avoidable hospitalisations, health managers and professionals should focus their efforts on providing effective primary healthcare to families of low socioeconomic levels, particularly prenatal and paediatric care, as well as encouraging breastfeeding and supporting young mothers. Strategies to improve children’s health by controlling such hospitalisations in Brazil should consider all residence areas and geopolitical macro-regions.

Variability in potentially preventable hospitalisations: an observational study of clinical practice patterns of general practitioners and care outcomes in the Basque Country (Spain)

OBJECTIVES

To explain the variability in the frequency of potentially preventable hospitalisations (ambulatory care sensitive conditions, ACSCs) based on factors at multiple levels (individual, health professional, health centre and health district), and specifically using resource efficiency indicators for general practitioners (GPs).

DESIGN

Cross-sectional study. We analysed primary care electronic health records and hospital discharge data using multilevel mixed models.

SETTING

Primary care network of the Basque Health Service (Spain).

PARTICIPANTS

All the residents in the Basque Country ≥14 years of age, covered by the public healthcare system (n=1,959,682), and all the GPs (n=1193) and health centres (n=130).

MAIN OUTCOME MEASURES

Individuals admitted for ACSCs, over a 12- month period.

RESULTS

Admissions for ACSCs were less frequent among patients who were female, middle-aged or from the highest socioeconomic classes. The health centre variables considered and GP list size were not found to be significant. After adjusting for the variables studied including morbidity, the risk of hospital admission was higher among individuals under the care of GPs with greater than expected numbers of patient visits and prescribing costs (OR=1.27 (95% CI 1.18 to 1.37); 1.16 (1.08 to 1.25)), and who make fewer referrals than the mean among their colleagues (OR=1.33 (1.22 to 1.44)).

CONCLUSIONS

When assessing activities and procedure indicators in primary care, we should also define outcome-based criteria. Specifically, GPs who are repeatedly visited by their patients, have higher prescribing costs and are more reluctant to refer patients to specialists obtain poorer outcomes.

Potentially avoidable hospitalizations in five European countries in 2009 and time trends from 2002 to 2009 based on administrative data

INTRODUCTION

Potentially avoidable hospitalizations in chronic conditions are used to evaluate health-care performance. However, evidence comparing different countries at small geographical areas is still scarce. The aim of the present study is to describe and discuss differences in rates and time-trends across health-care areas from five European countries.

METHODS

Observational, ecological study, on virtually all discharges produced in five European countries between 2002 and 2009. Potentially avoidable hospitalizations were operationally defined as a joint indicator composed of six chronic conditions. Episodes flagged as potentially avoidable were allocated to 913 geographical health-care areas. Age-sex standardized rates and standardized hospitalization ratios, as well as several statistics of variation, were estimated.

RESULTS

Four hundred sixty-two thousand seven hundred and ninety-two episodes were flagged as potentially avoidable. Variation in rates across countries was notable, from 93.7 cases per 10,000 inhabitants in Denmark to 34.8 cases per 10,000 inhabitants in Portugal. Within-country variation was also noteworthy, from 3.12 times among extreme areas in Spain to a 1.46-fold difference in Denmark. The highest systematic variation was found in Denmark (empirical Bayes 0.45) and the lowest in England (empirical Bayes 0.08). Rates and systematic variation remained fairly stable over time, with Denmark and England experiencing a statistically significant decrease (20% and 10%, respectively). Income and educational level, hospital utilization propensity, and region of residence were found to be associated with avoidable admissions.

CONCLUSION

The dramatic variation across countries, beyond age and sex differences, and its consistency over time, implies systemic, although differential, behaviour of the five health-care systems with regard to chronic care.

Primary Care Sensitive Hospitalization: users detect flaws on the access to services

The aim of this study is to analyze and understand the reasons for the occurrence of sensitive hospitalizations in accordance with users. Qualitative study conducted with users who were admitted to Pedreira General Hospital, in São Paulo. The data was collected through semi structured interviews and thereafter, transcribed and processed in the electronic program Alceste. When analyzing the content, the access was seized fundamentally as an empirical category, bringing up problems that later deserved, from the Brazilian Ministry of Health, a specific Program to improve the quality and access to primary care. The hierarchical and pyramidal organization shape from the health system in the city of São Paulo can be one of the important aspects for the access matter and established as an important restricting factor in the primary care role in reducing or even preventing the occurrence of these hospitalizations.

The effect of patient, provider and financing regulations on the intensity of ambulatory physical therapy episodes: a multilevel analysis based on routinely available data

BACKGROUND

Many studies have found considerable variations in the resource intensity of physical therapy episodes. Although they have identified several patient- and provider-related factors, few studies have examined their relative explanatory power. We sought to quantify the contribution of patients and providers to these differences and examine how effective Swiss regulations are (nine-session ceiling per prescription and bonus for first treatments).

METHODS

Our sample consisted of 87,866 first physical therapy episodes performed by 3,365 physiotherapists based on referrals by 6,131 physicians. We modeled the number of visits per episode using a multilevel log linear regression with crossed random effects for physiotherapists and physicians and with fixed effects for cantons. The three-level explanatory variables were patient, physiotherapist and physician characteristics.

RESULTS

The median number of sessions was nine (interquartile range 6-13). Physical therapy use increased with age, women, higher health care costs, lower deductibles, surgery and specific conditions. Use rose with the share of nine-session episodes among physiotherapists or physicians, but fell with the share of new treatments. Geographical area had no influence. Most of the variance was explained at the patient level, but the available factors explained only 4% thereof. Physiotherapists and physicians explained only 6% and 5% respectively of the variance, although the available factors explained most of this variance. Regulations were the most powerful factors.

CONCLUSION

Against the backdrop of abundant physical therapy supply, Swiss financial regulations did not restrict utilization. Given that patient-related factors explained most of the variance, this group should be subject to closer scrutiny. Moreover, further research is needed on the determinants of patient demand.